互通性電子病歷之辭彙標準－臨床醫學術語系統(SNOMED CT)之現狀與發展

臨床資訊透過互通性電子病歷(Interoperable Electronic Health Record, iEHR)之交換與分享，可達成醫療機構提升經營效率與促進病人照護品質的目的，近來我國及歐美先進國家均投入鉅資發展，而電子病歷的臨床辭彙標準中，最受各國重親及普通採用的爲臨床醫學術語系統(Systematic Nomenclature of Medicine-Clioical Term, SNOMED CT)。本研究除採用文獻分析法，整理SNOMED CT七個版本之演進及內容外，並以個案研究國內醫院發展現況，且以訪談方式了解臨床醫師及醫院資訊專業人員在作業內容系統建置上初步之需求。 SNOMED CT是一強大的臨床醫學術語(reference terminology)系統，它包含超過344,000概念(concepts)、913,000描述(descriptions)及1,360,000關係(relationships)，由概念、描述及關係三個可交換互通的資料表(tables)組成。SNOMED CT明確的定義醫學概念、同義字(synonyms)及概念之間的話義關聯，注重語義相互操作，並用類似關聯式資料庫方式，以階層式和關聯性組合概念間的多種關係，於是各類醫事專業人員可在不同照護地點查閱(index)、儲存(store)、回溯(retrieve)及累總(aggregate)病人臨床資訊，確保其可靠性和連貫性，並減少內容的變異(variability)，若應用其資訊編碼與參考術語於臨床資料上，除醫事專業人員記載病人病情及癌症登記外，資訊人員可用於發展電子病歷系統，醫療照護機爲可做爲支援決策、費用分析和臨床研究之工具，目前已有美、加拿大、英國等三十多個國家採用。展望未來，建構SNOMED CT辭彙標準將是醫療機構營運之重要競爭利器，亦爲醫院資訊建設之必然趨勢，而此標準之制訂需要政府、醫療機構及臨床、資訊等相關專業人員的積極合作，以建置符合國際之全國性臨床辭彙標準，使醫療院所及產業有所遵循，達到資料分享、交換及醫療照護品質捉弄的目的。

關鍵字

互通性電子病歷；臨床醫學術語系統

並列摘要

Exchange and sharing of clinical information through Interoperable Electronic Health Record (iEHR) can improve the healthcare organization's efficiency and enhance patient care quality. Following the footsteps of the US and many advanced European countries, Taiwan invested recently a big bundle in health information technology development. Systematic Nomenclature of Medicine-Clinical Term (SNOMED CT) has become one of the most valued clinical term standards of electronic health record and widely adopted by these countries interested. Aside from using literature review, by which we looked into the evolution and content of 7 existing versions of SNOMED CT, we also tried to find out the current situation of hospital development here in Taiwan through a case study, and to understand the preliminary needs of clinical physicians and information professionals in the establishment of operative matter system through interviews. SNOMED CT happens to be a powerful reference terminology system for clinical medicine, which contains more than 344,000 concepts, 913,000 descriptions, and 1,360,000 relationships. Clinical data are exchanged and interoperated by three, concept, description, and relationship, tab les. SNOMED CT clearly defines medical concepts, synonyms and semantic relationship, gives emphasis to the reciprocal manipulation of two meanings, and uses the like of relational database way to establish multi relations between concepts both in varied strata and channels, so that a patient's clinical data can be indexed, stored, retrieved, and aggregated by different participating clinicians at different locations of the caring, yet the reliability and coherence of it can be assured and the content variability be kept at minimum. 1n case of applying its information code system and reference terminology to clinical data, not only can healthcare workers use them to log patient's condition and do cancer registry, but also information personnel can develop electronic health record system with them, medical caring institutions can apply them as a versatile tool to support their decision making, cost analysis, and clinical research. Currently, more than 30 countries including the United States, Canada, and the UK have already adopted the system. In prospect, we believe that SNOMED CT terminology standard will be an important competition tool to run a healthcare institution, and an inevitable trend for hospital information construction. However, the formulation of this standard requires active collaboration of the government, the institution, and individual professionals in clinical medicine and information industry to establish a nationwide clinical terminology standard that meets internationally set criteria, and the goals include rendering healthcare institutions and the industry a standard to observe and facilitating information sharing and exchange, and thus vastly improving the quality of medical care.

並列關鍵字

Interoperable Electronic Health Record ； SNOMED CT

國際替代計量

互通性電子病歷之辭彙標準－臨床醫學術語系統(SNOMED CT)之現狀與發展

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